§ 26-18-121 — Overinsurance; all coverages

Wyoming § 26-18-121

• Jurisdiction: Wyoming
• Title 26: Insurance Code
• Ch. 18: DISABILITY INSURANCE POLICIES

Text

(a) "Overinsurance: If, with respect to a person covered
under this policy, benefits for allowable expense incurred
during a claim determination period under this policy together
with benefits for allowable expense during that period under all
other valid coverage, without giving effect to this provision or
to any 'overinsurance provision' applying to the other valid
coverage, exceed the total of the person's allowable expense
during the period, this insurer is liable only for the
proportionate amount of the benefits for allowable expense under
this policy during the period as:
(i) The total allowable expense during the period
bears to:
(A) The total amount of benefits payable during
the period for the expense under this policy and all other valid
coverage, without giving effect to this provision or to any
'overinsurance provision' applying to the other valid coverage;
less
(B) In this paragraph any amount of benefits for
allowable expenses payable under other valid coverage which does
not contain an overinsurance provision.
(b) The provisions of subsection (a) of this section do
not operate to increase the amount of benefits for allowable
expense payable under this policy with respect to a person
covered under this policy above the amount which would have been
paid in the absence of these provisions. This insurer may pay
benefits to any insurer providing other valid coverage in case
of overpayment by the insurer. Any such payment discharges this
insurer's liability as fully as if the payment is made directly
to the insured, his assignee or his beneficiary. If this insurer
pays benefits to the insured, his assignee or his beneficiary,
exceeding the amount payable if the existence of other valid
coverage had been disclosed, this insurer has a right of action
against the insured, his assignee or his beneficiary to recover
the amount which would not have been paid had there been a
disclosure of the existence of other valid coverage. The amount
of other valid coverage which is on a provision of service basis
shall be computed as the amount the services rendered would have
cost in the absence of that coverage.
(c) For the purpose of the provisions in subsections (a)
and (b) of this section:
(i) 'Allowable expense' means one hundred ten percent
(110%) of any necessary, reasonable and customary item of
expense which is covered, in whole or part, as a hospital,
surgical, medical or major medical expense under this policy or
under any other valid coverage;
(ii) 'Claim determination period' with respect to any
covered person means the initial period of .... (insert period
of not less than thirty days) and each successive period of a
like number of days, during which allowable expense covered
under this policy is incurred because of that person. The first
period begins on the date when the first expense is incurred,
and successive periods begin when an expense is incurred after
expiration of a prior period, or, instead: 'Claim determination
period' with respect to any covered persons means .... (insert
calendar or policy period of not less than a month) during which
allowable expense covered under this policy is incurred because
of that person;
(iii) 'Overinsurance provision' means this provision
and any other provision which may reduce an insurer's liability
because of the existence of benefits under other valid
coverage."
(d) The policy provisions specified in subsections (a)
through (c) of this section may be inserted in all policies
providing hospital, surgical, medical or major medical benefits.
The insurer may make this provision applicable to either or both
other valid coverage with other insurers and other valid
coverage with the same insurer. The insurer shall include in
this provision a definition of "other valid coverage" approved
as to form by the commissioner. The term may include hospital,
surgical, medical or major medical benefits provided by group,
blanket or franchise coverage, individual and family-type
coverage, Blue Cross-Blue Shield coverage and other prepayment
plans, group practice and individual practice plans, uninsured
benefits provided by labor-management trusteed plans, or union
welfare plans, or by employer or employee benefit organizations,
benefits provided under governmental programs, worker's
compensation insurance or any coverage required or provided by
any other statute, and medical payments under automobile
liability and personal liability policies. Other valid coverage
does not include payments made under third party liability
coverage as a result of a determination of negligence, but an
insurer may include a subrogation clause in its policy. As part
of the proof of claim, the insurer may require the information
necessary to administer this provision.